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Chickenpox in Children, Adults

and Pregnancy: What to do?

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BACKGROUND

> 90% of population infected by 15 yrs

attack rates 90% for household

contacts

morbidity

bacterial skin infections

pneumonia encephalitis, post varicella cerebritis

days from school/work

hospitalizations (

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BACKGROUND

risk of death:

lower for children than infants

increases with age for adolescents/adults

30% for perinatally exposed infants

2/100,000 aged 1-14

2.7/100,000 aged 15-19

25.2/100,000 aged 30-49

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STRATEGIES

Prevent infection?

infection control

passive vaccination (VZIG)

active vaccination (live attenuated)

Treat infection? who to treat?

what to treat with?

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VARICELLA IN CHILDREN

Prevention Options

-vaccination

-school omission

Treatment Options

-symptomatic

-antiviral medications

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VARICELLA VACCINE:

Efficacy

96-100% seroconversion within 4-6 weeks

post vaccination

> 90% with high titers after 20 years

< 2% breakthrough of varicella 2 years out

attenuated disease

Not available in Pakistan

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VARICELLA VACCINE:

Side

Effects

fever (12%)

pain at site (2%)

rash at injection site (1.5%)

generalized rash (1.5%)

transmission of vaccine virus

higher if vaccinees are immunocompromised

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WHO SHOULD BE

VACCINATE

D?YES

> 1 year of age

varicella susceptible no history of chicken

pox

no contraindications

NO

< 1 year of age

immunedeficient inhousehold

pregnancy

mild natural

chickenpox

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VARICELLA IN CHILDREN

Usually previously well children develop malaise and

low grade fever which rises once the rash appears. The

rash begins along the hairline on face as macules which

progresses to tiny vesicles with surrounding

erythema.(Dew drops on rose petal appearance) . Rash

then appears in successive crops over the trunk and

extremities. They heal in 7-10 days. Sometimeshemorrhage may occur within the vesicles which may

be mistaken as Meningococcemia.

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SCHOOLWITHDRAWALS

The

Evidence

contagious 1-2 days before the rash

until all lesions crusted documented transmission of infection

to classmates prior to rash (AJDC 1989-Brunell)

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*RC

TRandomized Control

Trial

ACYCLOVIR IN CHILDREN

The

Evidence

Balfouret alJ Peds 1990 & Dunkle et alNEJM 1991

RCT of 102 and 815 children

acyclovir (20mg/kg/dose) qid vs

placebo

qlesions, qfever, qitching

no change in complications or titers

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ACYCLOVIR IN CHILDREN

no serious adverse drug reactions noted

cost of medications needs to be

considered!!!!

**acyclovir is not routinely

recommended for the treatment of

chickenpox in healthy children

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PROPHYLACTIC

ACYCL

OVIR IN CHIL

DREN

40 mg/kg/day after exposure

q symptomatic cases with acyclovir vs

placebo (16% vs 100%) (Asano et alPediatrics1993)

79-85% still had serologic evidence ofinfection

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PROPHYLACTIC

ACYCL

OVIR IN CHIL

DREN q severity if acyclovir given for two

weeks (Suga et alArch Dis Child 1993, PIDJ 1998)

development of resistance is a concern

**routine acyclovir prophylaxis not

recommended in otherwise healthy

children

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VARICELLA IN HEALTHY

ADULTS

38 yo healthy man with no previously

documented chicken pox develops

fever and vesicular rash 18 days after

his son recovers from chickenpox.

Has lesions in mouth and urethra and

increasing cough.

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VARICELLA IN HEALTHY

ADULTS

o incidence of pneumonia

ohospitalization rates (10%)

omortality compared to children

otime from work/school

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VARICELLA IN ADULTS

The

Evidence

RCTs in adults with acyclovir given

within 24 hours of onset

800mg qid x 5 days

q duration, q severity of illness(Wallace et alAn n Int Med; 1992, Feder Arch Intern Med;1990)

No studies to date with valacyclovir or

famciclovir

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VARICELLA IN PREGNANCY

pregnancy alters cellular immunity

needed to fight viral infections

opneumonitis omortality

omaternal complications in 2nd and

3rd trimester premature labour/delivery, IUGR

small risk of fetal infection

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VARICELLA IN PREGNANCY-

WhatT

o Do?

prevent infection

VZIG

infection control

diagnose early treat infection

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VARICELLA IN PREGNANCY-

The

Evidence

no evidence to suggest that maternal

acyclovir prevents fetal infection

no evidence of teratogenic effect of

acyclovir at therapeutic doses

high doses havein vitro

effects

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VARICELLA IN PREGNANCY

treat based on maternal status

800mg qid x 5 days

IV therapy if pneumonia

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VARICELLA IN FETUS

2.2% transmission to fetus (1.2%-

4.9%) (Pastuszaket alNEJM 1994)

intrauterine infection more common in1st trimester

congenital infection

scarring, limb deformities, cataracts, CNSinvolvement, chorioretinitis

neonatal or childhood zoster (0.8% -

1%)

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VARICELLA IN NEONATES

during maternal varicella 24% of

fetuses get transplacentally infected

critical times is 5 days before to 2 days after birth neonates < 28 weeks gestation or

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VARICELLA IN NEONATES

Infant born at full term following

uncomplicated delivery. Mother

noticed to have varicella lesions 2 days

prior to delivery with low grade fever.

Infant is completely well with no skin

lesions, no fever etc.

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VARICELLA IN NEONATES

The

Evidence VZIG if peripartum maternal infection

(Hanngren Ket alScand J Infect Dis 1985)

attack rate still 51%

incubation period of 11 days

attenuates infection (Milleret al. Lancet 1989 )

q mortality rate (1-2%), q lesions no literature regarding the use of

acyclovir for prevention of disease in

this group

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VARICELLA IN NEONATES

Perinatal Exposure

treat with acyclovir due to high mortality

< 4 weeks of age treat if mother is not immune, if infant

born < 28 weeks gestation, < 1000gm,

sick in NICU

no clinical trials to date however good

studies with acyclovir in other neonatal

infections